Provider Demographics
NPI:1356457535
Name:MARKHAM, PHILLIP LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LYNN
Last Name:MARKHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 PINE ST
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537
Mailing Address - Country:US
Mailing Address - Phone:712-755-5342
Mailing Address - Fax:712-755-5666
Practice Address - Street 1:2105 PINE ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537
Practice Address - Country:US
Practice Address - Phone:712-755-5342
Practice Address - Fax:712-755-5666
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA73741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0299883Medicaid